Andrew Spencer Wing · Prevention of Future Deaths report

An inquest into the death of Andrew Spencer Wing was opened on 23rd May 2019 and resumed on the 2nd April 2020 and concluded on 6th March 2020 I concluded with a narrative conclusion that:

Andrew Wing suffered an acute onset of pain in his chest at 1am on the 13th January 2019. He attended at St Peter’s Hospital, Chertsey at 16.47 where he was seen in the minor injuries department by which time his pain had diminished and presented as mild. He underwent investigations which ruled out a myocardial infarction. An aortic dissection was one of the differential diagnoses the possibility of which was recognised and for which the necessary diagnostic investigation was a CT Aorta. Despite the index of suspicion being sufficient to require this to be undertaken it was not and had it been it would have identified an aortic dissection. He was discharged and died from the effects of the aortic dissection on the 15th January 2019 at the Ship Hotel in Weybridge. Had a dissection been identified on the 13th January 2019 prior to discharge he would have been subject to the necessary emergency surgery which he would have survived.

The cause of death was :

1a Haemopericardium

1b Aortic Dissection

1c Hypertension

I concluded with the narrative conclusion set out above.

Andrew Wing had a long history of untreated hypertension having refused medication for the condition. In the early hours of the 13th January 2019 he suffered an acute onset of severe pain in his left side. He attended St Peter’s Hospital, Chertsey by which time the pain had diminished. He underwent investigations, an ECG, Chest Xray and blood tests. The blood tests did not show a rise in troponin levels. The Chest Xray was read by 2 emergency clinicians who thought it appeared normal. He was discharged from hospital and died on the 15th January 2020 from the effects of the aortic dissection. Aortic dissection was one of the differential diagnoses considered but a CT Aorta was not undertaken.

The evidence showed that:
1. The chest Xray taken on the 13th January 2019 showed an image which was at least at the upper end of normal and in the context of a differential diagnosis of aortic dissection should have led to a CT Aorta being undertaken. Plain X rays are not diagnostic of aortic dissections. The consultant radiographer who reviewed the X ray remotely on the 14th January 2019 reported it as normal but had not been made aware of the differential diagnosis of aortic dissection. If he had been made aware of this he would have advised that a CT Aorta be undertaken.
2. It is common practice for reviews of X rays to be undertaken by radiographers. The clinical information provided to them is sparse. More detailed and specific information would assist them in undertaking their reviews.